1831415512 NPI number — RENE' JOHNSON CMT, LMT, MMP

Table of content: RENE' JOHNSON CMT, LMT, MMP (NPI 1831415512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831415512 NPI number — RENE' JOHNSON CMT, LMT, MMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
RENE'
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CMT, LMT, MMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831415512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 COLISEUM CROSSING
Provider Second Line Business Mailing Address:
SUITE 216
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-842-9144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 BAKER ROAD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-842-9144
Provider Business Practice Location Address Fax Number:
757-873-1846
Provider Enumeration Date:
04/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0019007580 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: 0019007580 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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